Notification of Planned Action
Office of Developmental Disabilities Services
Date of notice:
Effective date of planned action:
Individual’s name:
Individual’s date of birth:
Street address:
City:
State:
Legal guardian’s name (if applicable):
Individual’s prime number:
ZIP code:
The purpose of this Notification is to inform you of the planned action below. The
planned action is based on Oregon Administrative Rules and the records listed in this
Notification. If you disagree with the decision, you have the right to request a hearing,
as provided in ORS chapter 183 and OAR 411-318-0025. For information on how to
request a hearing and the hearing process, see Parts 1– 4 on the following pages.
If you have questions, if your situation changes, or if you have relevant records
not included below, please contact the person at this agency:
Notifying agency:
Notification completed by: Select one
Other:
Name:
Phone:
Planned Action
Your request for services from the DHS Developmental Disabilities Program has
been denied.
Your current services will not change, but your specific request for
denied.
has been
Your services are going to be select one.
Specific services involved:
Reason for Action
After reviewing the following Oregon Administrative Rules and the records listed below,
DHS is taking this action because
.
Relevant Oregon Administrative Rules
The planned action is based on the following OAR(s) (include subsections):
943-001-0020(3);
;
;
Oregon Administrative Rules can be found on the website of the Oregon Office of the
Secretary of State.
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Records Used in the Decision
Date
Type of record/report/evaluation
Author
Other information and comments:
You have the right to review these records. You can request the records by contacting
the person listed on page 1.
Notice of Hearing Rights
 You have the right to challenge this decision by requesting a contested case
hearing. Hearings are held by an Administrative Law Judge and the Office of
Administrative Hearings, which is independent from DHS. If you want a hearing, you
must request a hearing within 90 calendar days of the date of this Notification. If
you are being denied services, see Parts 1, 2 and 4 (below). If your services will be
reduced, suspended or terminated, see Parts 1 – 4 (below).
 You can request to have an informal discussion about this Notification by contacting
the local office where you receive services (Brokerage, CIIS or CDDP). An informal
discussion will not affect your right to a hearing. If you verbally request a hearing
during the informal discussion, the person you are speaking with can request a
hearing for you. If you choose to have an informal discussion, the deadline to
request a hearing does not change.
 Note to military personnel: Active duty service members have a right to stay these
proceedings under the federal service members Civil Relief Act. For more
information, you may contact the Oregon State Bar (1-800-452-8260), the Oregon
Military Department (1-800-452-7500) or find the nearest military legal assistance
office here: http://legalassistance.law.af.mil/content/locator.php. (SB125).
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Part 1 — How do I ask for a hearing?
Ways to request a hearing:
1. Fill out an Administrative Hearing Request Form (SDS 0443DD) and send it to:
Oregon Developmental Disability Services (ODDS), Attn: Administrative Specialist,
500 Summer St., E-09, Salem OR 97301; or
2. Fax an Administrative Hearing Request Form (SDS 0443DD) to 503-373-7274; or
3. Make a verbal request for a hearing by speaking directly with the person listed on
Page 1, your caseworker, or a DHS or ODDS employee.
You can request the form from:
at:
or follow this link: https://apps.state.or.us/Forms/Served/se0443dd.doc.
If you need help filling out this form, call:
at:
.
DHS must receive your request for a hearing within 90 calendar days from the date
of this Notification (in the upper left corner on Page 1). If your services are being
reduced, suspended, or terminated, you can continue to receive services until a
hearing is held and a final order is issued. To receive services until a final order is
issued, request a hearing before the ‘effective date of planned action’ on this
Notification. See Part 3 for more information on continuing services.
Part 2 — What are my hearing rights?
 What happens after I request a hearing?
The laws about your right to request a hearing and the hearing process are in ORS
chapter 183 and OAR 137-003-0501 through 137-003-0700. If you request a hearing,
a hearing representative from the Office of Administrative Hearings will contact you. At
the hearing, you can explain why you do not agree with this decision and you can
have other people testify for you.
 Who can help with my hearing?
You have the right to be represented by counsel, or you can choose to have a family
member or another layperson represent you at the hearing. You may be able to get
free legal services from Disability Rights Oregon (1-800-452-1694), Legal Aid
Services of Oregon (1-800-520-5292) or the Oregon State Bar (1-800-452-8260).
 What happens if there is no hearing?
You may lose your right to a hearing if you do not ask for a hearing on time, if you
withdraw your hearing request, or if you do not appear at your hearing. If a hearing
is not held, this Notification of Planned Action will be DHS’s final decision (called a
Final Order by Default). You will not receive a separate Final Order by Default. DHS
refers to the case file, along with any materials submitted in this matter, as “the
record.” DHS uses the record to support the Final Order by Default.
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Part 3 — How can I keep getting benefits/services until my hearing?
(This applies only if you currently receive services from the Developmental Disabilities
Program and this Notification will terminate, reduce or suspend your services.)
 You can ask that your services remain the same until the hearing decision
(continuing services). You must request a hearing by the ‘effective date of planned
action’ on this Notification in order to receive continuing services.
 You may also receive continuing services if you request a hearing and select “yes”
on the Hearing Request Form (SDS 0443DD); you must do this within 10 business
days after the effective date of planned action.
 If you elect to receive continuing services and you lose the hearing, you may be
asked to pay for the services you receive between the effective date of planned
action and the date of the Final Order. If you do not want to receive continuing
services, select “no” on the Hearing Request Form (SDS 0443DD).
Part 4 — Can I request to have a hearing within five working days?
 You may have the right to an “expedited hearing” (within five (5) working days), if
you are denied a medical service that creates an immediate, serious threat to your
life or health, or if DHS denied your request to continue to receive services until
your hearing.
 You must request an expedited hearing on the Hearing Request Form (SDS 0443DD).
The Department of Human Services (DHS) and the Oregon Health Authority (OHA) do
not discriminate against anyone. This means that DHS/OHA will help all who qualify
and will not treat anyone differently because of age, race, gender, color, national origin,
religion, political beliefs, disability or sexual orientation. If you believe DHS or OHA
treated you differently for any of these reasons, you may file a complaint with the
Governor’s Advocacy Office by calling 1-800-442-5238, or contacting the office at:
Governor’s Advocacy Office, 500 Summer Street NE, E-17, Salem, OR 97301.
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